Annette DuBard, MD, MPH is the SVP for Informatics and Evaluation at Community Care of North Carolina, where she has led efforts to advance population health analytics and information systems used statewide to facilitate care coordination and quality improvement in practices and communities; to support targeted care management for patients with complex healthcare needs; and to monitor quality, utilization, and cost outcomes. A graduate of Rhodes College and the Johns Hopkins University School of Medicine, she completed family medicine and preventive medicine residency training, with a master’s degree in health policy and administration, at the University of North Carolina at Chapel Hill. Her background includes several years of full time clinical practice in the community health center setting, and research interests in underserved populations, delivery system reform, and population health management strategies.

00:00 Annette explains CCNC, Community Care of North Carolina.
01:00 CCNC is not a healthcare provider, but an infrastructure that operates between the payer and the provider.
02:30 The primary providers that CCNC operates their program with.
03:30 How CCNC works as an arm of providers, and what entities hold them accountable.
05:00 The Complex Care programs that CCNC runs, and what these are/how they work.
08:30 Moving away from disease management, and taking a holistic view of individual healthcare management.
11:00 “It is not just recognizing disease morbidity, but you are looking for how people are using care.”
14:20 “High risk does not necessarily mean highly impactable.”
14:45 Finding outliers in patterns of care.
20:00 The difference between highly impactable patients and “super-users.”
23:30 How other providers are able to achieve the models that CCNC uses, without needing the large volume of data that CCNC is able to use.
26:30 What CCNC is doing to build out their programs and enable larger community and industry collaboration.
28:30 Check out the links above for more information.
29:00 Notable failures within the industry that Annette has seen firsthand.
33:00 Annette’s advice for disease management entrepreneurs.
34:50 “It’s really all about appropriate targeting of what we have to offer.”